The Irish Air Accident Investigation Unit (AAIU) published the final investigation report into a serious runway incursion incident at Dublin in October 2010.

On 16 October 2010 a THY Turkish Airlines Boeing 737-800 aircraft (TC-JGG) taxied onto the active runway 28 at Dublin Airport (DUB), Ireland. At the same time a Germanwings Airbus A319 aircraft (D-AGWJ) was on short final approach to land on the same runway. Dublin ATC had cleared TC-JGG to taxi in preparation for subsequent departure from runway 28 and the aircraft was instructed to hold short of the runway. D-AGWJ had been cleared to land. The crew of the landing aircraft observed TC-JGG approaching the runway and initiated a go-around manoeuvre. Simultaneously ATC issued a go-around instruction. D-AGWJ descended to a height of less than 200 ft above the ground, less than 0.4 nautical miles (nm) from its touchdown point, before it climbed away.

The AAIU established the following Probable Cause:
The crew of TC-JGG did not comply with their taxi clearance limit as issued by ATC, and the aircraft entered an active runway without permission.

Contributory Factors:

Distraction of the crew of TC-JGG during the taxi by head-down cockpit tasks. The Operator’s Operations Manual states that, while taxiing, “both pilots must be very careful about the environment”.

Misinterpretation by the crew of TC-JGG of a statement concerning a further holding position in their Jeppesen Manual.

The absence of a verbal cross-check procedure for runway entry in the Operations Manual of TC-JGG.

Six safety recommendations were issued:

Turkish Airlines should consider an amendment to their Operations Manual Part-B Chapter 2 Normal Procedures to ensure that the handling pilot maintains an external look-out at all times during taxi. (IRLD2011018)

Turkish Airlines should consider an amendment to their Operations Manual Part-B Chapter 2 Normal Procedures to include a verbal cross-check between crew members when an aircraft is about to enter or cross a runway, whether active or non-active. (IRLD2011019)

The Dublin Airport Authority, in conjunction with the Irish Aviation Authority, should consider originating an amendment of AIP Ireland, Section EIDW AD 2.20, paragraph 8.4, to clarify the statement “A further holding position is established on RWY 16/34”. (IRLD2011020)

The Dublin Airport Authority, in conjunction with the Irish Aviation Authority, should consider originating an amendment of AIP Ireland, Section EIDW AD 2.20, to include a statement that the holding position for RWY 34 on TWY E1 is combined or co-located with the Cat I holding position for RWY 28 on TWY E1.(IRLD2011021)

The Dublin Airport Authority, in conjunction with the Irish Aviation Authority, should consider the provision of stopbar lights on TWY E1 at the combined holding position for RWY 34 and RWY 28 Cat I.(IRLD2011022)

The Irish Aviation Authority should consider the inclusion of a reference to both RWYs 28 and 34 in ATC instructions to aircraft taxiing in the area of the combined runway holding position. (IRLD2011023